Provider Demographics
NPI:1194195883
Name:RIDGE EYE CARE
Entity Type:Organization
Organization Name:RIDGE EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDETNIALING SPECIALIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-755-0693
Mailing Address - Street 1:311 PARK PLACE BLVD
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-4904
Mailing Address - Country:US
Mailing Address - Phone:727-755-0693
Mailing Address - Fax:727-755-0679
Practice Address - Street 1:7056 SKYWAY
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-3960
Practice Address - Country:US
Practice Address - Phone:530-891-1900
Practice Address - Fax:530-895-1531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659502201Medicaid